Consent for Medical Treatment & Assignment of Benefits and Release of Information
Person Authorized to Consent: To protect the rights and honor the wishes of our patients and their authorized representative(s), Cincinnati Children’s must know the name, relationship and phone number of the person authorizing consent. The authorized representative must authorize hospitalization and any special procedures except in emergency situations determined by our medical staff or when the patient is legally permitted to consent to their own treatment. Patients should be discharged to an appropriate person pursuant to the Medical Center Policy entitled Persons Authorized to Consent for Admission, Treatment and Discharge of Patients.
CONSENT FOR MEDICAL TREATMENT
I authorize Cincinnati Children’s and the provider(s) treating me/my child to use any treatment or procedures that may be needed in the medical or dental care and that may be reasonably expected to be part of the normal inpatient or outpatient service. This includes drugs, medicines, laboratory procedures, X-ray procedures and diagnostic testing (whether performed at Cincinnati Children’s or at nearby facilities), immunizations, preventive medicine procedures and routine recreational activities, the use of local anesthesia during laboratory procedures and diagnostic testing (whether performed at Cincinnati Children’s or nearby facilities). This consent for treatment does not authorize any surgical or medical procedure using general anesthesia or sedation. I understand that during the diagnostic or treatment process, the medical team may determine that it is in the best interest of me/my child to refer them to other services within Cincinnati Children’s. I authorize this transfer and treatment. This will authorize the providers to provide services until cancelled by me in writing. I understand that Cincinnati Children’s may take pictures, films, or audiovisual recordings (“images”) of the patient to use for diagnosis, treatment, patient identification and internal purposes such as staff training, medical education, performance improvement, and other organizational activities. Cincinnati Children’s may provide certain services using telehealth technology, including transmission of images, video and audio that are secured for privacy. The remote provider will determine if the condition being diagnosed or treated is appropriate for telehealth. I understand that there is no guarantee of diagnosis, treatment, or prescription for myself/my child. I understand that I/my child may have to travel to see a health provider in-person for certain diagnosis and treatment or in the event of a technical failure.
ASSIGNMENT OF BENEFITS (FINANCIAL RESPONSIBILITY)
I authorize payment to Cincinnati Children’s for all hospital, physician/professional, and ancillary services provided. I assign to Cincinnati Children’s all rights, title, and interest in and to any third-party benefits due from any and all insurance policies, employee benefit plans, and/or responsible third-party payers in an amount not to exceed Cincinnati Children’s regular and customary charges for services rendered. I accept responsibility for determining whether services provided to me are covered by my insurance or other third-party payers. I understand that I am responsible to Cincinnati Children’s for charges not covered by my insurance company for services provided. If a referral from my insurance company is required for payment to be made, I assume responsibility for getting this referral and for all charges associated with this account if no referral is obtained. I consent to any request for review or appeal by Cincinnati Children’s to challenge a determination of benefits made by a third-party payer, insurance carrier, or employee benefit plan.
RELEASE OF INFORMATION
I authorize Cincinnati Children’s and any treating provider to release any and all information related to the care and treatment of the patient that may be requested or required by the third-party payer (insurance company, government agency or its respective agents, or employer), to the extent needed for payment. I also authorize the release, as needed, of information from my child's medical record to appointees of the Cincinnati Children’s medical staff, its allied health professionals, employees and other agents, as well as to accrediting and licensing/regulatory entities who have agreed to keep such information confidential. This may be used to review or audit the performance of Cincinnati Children’s, its medical staff, its allied health professionals, its employees and/or agents helping Cincinnati Children’s in medical care or health care operations. Other disclosures of protected health information may occur in accordance with the Notice of Privacy Practices. Patient information may be stored electronically and used to improve clinical outcomes. This authorization includes the release of information concerning HIV testing, diagnosis or treatment of AIDS, AIDS-related conditions, psychiatric/psychological diagnosis and treatment, and substance use disorder diagnosis and treatment (42 CFR Part 2). I authorize Cincinnati Children’s to use and release substance use disorder records like any other treatment records at Cincinnati Children’s. Records used or disclosed pursuant to this consent may be subject to redisclosure by the recipient and no longer protected by 42 CFR Part 2. Cincinnati Children’s will never release these records for any civil, criminal, administrative, or legislative proceeding involving you unless ordered by a court.
Your consent for release of 42 CFR Part 2 records is voluntary and will stay active until you submit a written request to cancel it, which can be done by writing to the Health Information Management Department at Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5015, Cincinnati, Ohio 45229-3039. Revocation will not apply to releases made before receipt of your revocation and could impact your ability to receive 42 CFR Part 2 services.
